ANESTHETIC PROCEDURE RELEASE FORM

  • *If you are unsure of this form and would like to discuss it with a staff member when you come in for surgery, please click the link below to bypass the release form.

    https://form.jotform.com/230616437195054

  • ANESTHETIC PROCEDURE RELEASE FORM

  • Format: (000) 000-0000.

  • FEMALES ONLY

  • Hover above each field to read additional information
  • COST FOR CBC/CHEM LABWORK IS $138*
  • COST FOR IV CATHETERIZATION AND IV FLUIDS ARE $103*
  • HISTOPATHOLOGY $135 (MASS REMOVAL/BIOPSY ONLY)

  • VACCINES/ANNUAL TESTING 

    These can be completed early if they coming up due. 
  • CANINES ONLY

    CANINES ONLY

    Hover over each field to read additional information
  • RABIES - Rabies is required per TVC policy at 16 weeks of age - If proof of current rabies is not provided, vaccine one will be administered at owners expense.
  • DHLPP
  • LEPTOSPIROSIS
  • LYME
  • BORDETELLA (if they go to a kennel or groomer)
  • 4DX TEST ***Tests for Heartworm disease, as well as 3 tick born diseases - Lyme, Anaplas, and Ehrlichia.
  • FECAL EXAM
  • SAVE THIS LIFE MICROCHIP
  • FELINES ONLY

    FELINES ONLY

    Hover above each field to read additional information
  • RABIES - Rabies is required per TVC policy at 16 weeks of age - If proof of current rabies is not provided, vaccine one will be administered at owners expense.
  • FVRCP
  • FELINE LEUKEMIA (strongly recommended for outside cats)
  • FELINE LEUKEMIA TEST
  • FECAL EXAM
  • SAVE THIS LIFE MICROCHIP

  • DENTAL PROCEDURES ONLY

  • DO YOU AUTHORIZE EXTRACTIONS IF THEY ARE NECESSARY?
  • Format: (000) 000-0000.

  • Extractions are only done if they are deemed necessary **If you answer no and we cannot reach you in a timely fashion, your pet will be woke up from anesthesia and rescheduled for extractions. A new estimate can be provided for this 2nd procedure at your request. **
  • WOULD YOU LIKE A BUSTER COLLAR? ($12)*
  • DO NOT RESUSCITATE (DNR) ORDER - (please hover over the field for additional information - click the field if filling out the form via cellular phone)*

  • If you answered yes to the above field, please read the below statement and sign accordingly.

     

    I, the undersigned, being of sound mind and legal age, willfully and voluntarily make this declaration to state my desires and direct that resuscitation be withheld or withdrawn in the event of my pet listed above has cardiac or respiratory arrest. It is my intention that this order be honored by my family, my veterinarians, and all others who may partake in my pets health care.

  • By typing your name below, you are also indicating you have been informed of the risks involved with anesthesia, and you have had an opportunity to discuss these risks with a veterinarian. Your signature further indicates you accept these risks and give the Thompson Vet Clinic permission to anesthetize your pet.​Thompson Vet Clinic will utilize all reasonable precautions against injury, escape, or death of your pet.
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